Health inspection·December 2, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free of falls during a mechanical lift transfer for 1 of 3 (R6) residents reviewed for falls in the sample of 19.This past non-compliance occurred between 10/1/25 and 10/8/2025.Findings Include:R6's admission Record with a print date of 11/29/25 documents R6 was admitted to the facility on [DATE] with diagnoses that include peripheral vascular disease, acquired absence of left leg, hypertension, anemia, history of falls, unsteadiness on feet, abnormal posture.R6's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score of 09, indicating a moderate cognitive deficit. This same MDS documents R6 is dependent on staff for transfers.R6's current Care Plan documents a Focus area of I have an ADL (activities of daily living) self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day right BKA (below knee amputation) with activity throughout the day right BKA with wound infection, PVD (peripheral vascular disease), Anemia, CKD (chronic kidney disease) stage 3, unsteadiness on feet, HTN (hypertension), history of falls, uses a wheelchair for mobility. Date Initiated: 01/18/2022. This Focus area includes the intervention of, .Transfers: (R6) requires Mechanical Lift Hoyer Lift with 2 staff assistance for transfers. Date Initiated: 01/21/2020 R6's Progress Notes dated 10/1/2025 documents, CNA (Certified Nursing Assistant) approached this nurse in tears asking for help. CNA was attempting to transfer resident from wheelchair to bed with (mechanical lift) and according to her she noticed that the resident had started to fall backward due to strap not being connected. She then held and guided res (resident) to floor. Upon entering room this nurse observed resident laying on her back on the floor. Res denied any pain. No injuries were reported by res and none were observed. Res did hit head on floor. Vitals were taken, all WNL (within normal limits). Neuro (neurological) checks were initiated, all WNL. Resident assured this nurse and CNA that she was not in pain. Residents POA (power of attorney) was notified and non emergent was sent to (name of physician).R6's Progress Note titled IDT (Interdisciplinary Team) Note dated 10/02/2025 documents, CNA was attempting to transfer resident from wheelchair to bed with (mechanical) lift and according to CNA she noticed that the resident had started to fall backward due to strap not being connected. She then held and guided res to floor. Upon Nurse entering room she observed resident laying on her back on the floor. Res denied any pain. No injuries were reported by resident, and none were observed by assessment. Inservice for facility policy and procedure for (mechanical) lift transfers and CNA transfer observations.On 11/29/25 at 10:34 AM, V12 (CNA) stated she was transferring R6 using the mechanical lift and she assumed she forgot to hook one of the straps. V12 stated during the transfer she realized there was something wrong, so she went under R6, hugged her, and lowered her to the ground. V12 stated she got the nurse and R6 was assessed and had no injuries. V12 stated it was the first time she had attempted to transfer a resident without a second staff member present. V12 stated after the incident she was retrained by her supervisor and so were Page 1 of 2 145918 145918 12/02/2025 The Haven of Bridgeport 900 East Corporation Bridgeport, IL 62417

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the other CNA's. V12 stated they also had to demonstrate they knew how to transfer a resident using a mechanical lift.On 12/01/25 at 4:29 PM, V1 (Administrator) stated she had not had any complaints/concerns related to unsafe transfers other than the incident of V12 attempting to transfer R6 using a mechanical lift without assistance of another staff member. V1 stated the facility policy is that all mechanical lift transfers be done with assist of two staff. V1 stated after the incident they retrained staff, had all CNA's demonstrate a transfer using a mechanical lift, and put monitoring in place to ensure staff were transferring residents safely.The facility policy titled Lifting Machine, Using a Portable dated August 2008 documents, The purpose of this procedure is to help lift residents using manual lift device The portable lift should be used by two staff members .Prior to the survey date of 12/2/2025, the facility had taken the following actions to correct the deficient practice:1. The facility's Inservice Sheet dated 10/1/2025 documents CNA's were trained on (Mechanical) Lift Transfers To provide safe transfers using the (mechanical) lift. (Mechanical) lift policy and procedures .2. The facility's (Mechanical) Lift check off in-service sign in sheet dated 10/2/2025 documents signatures of CNA's who attended the inservice as titled.3. The facility's observational audit sheets titled Free of Accidents/Hazards/Supervision/Devices document audits began 10/8/2025.4. The facility's Past Noncompliance Corrective Action Template dated 10/1/2025 documents, Noncompliance issue: Safe (Mechanical) lift transfers . Resident(s) name: (R6) Immediate Intervention: Education- training on policy and procedure regarding proper use of a manual lift device and two person required. Residents who may be affected by the noncompliance: List all residents who may be affected by the noncompliance. Resident would need utilization of a (mechanical) lift device could be effected [sic]. Trends and concerns: One person transfer. Root Cause: Waiting on other CNA to provide two assist help. Corrective Actions: Review the resident's care plan for transfer type, discussed with IDT (Interdisciplinary Team) and updated. Two staff member present for all (mechanical) lift transfers for all residents who require (mechanical) lift device. Audits made three residents weekly for six weeks or until compliance made. All concerns discussed at QAPI (Quality Assurance and Performance Improvement), Physician and POA (power of attorney) notified. Staff Training . Education CNA's were educated on policy and procedure regarding proper use of a manual lift device and two person required Follow up Investigation completed, resident received no harm, risk management completed. Administrator/DON (Director of Nurses) and or designee will perform random safe resident handling while utilizing mechanical lift audits weekly to assure resident safety. Also, the results of the above audits will be reviewed in the Quality Assurance Meeting monthly until 100% compliance is achieved for 3 consecutive months. The QAA Committee will identify any trends . 145918 Page 2 of 2